The Paramedic Degree: Good or Bad?

Does it make a difference?

I had to complete a degree to be a paramedic in my country. Without it, I wouldn’t have been considered for a position. The degree is the minimum standard of education for a graduate paramedic. Many EMS employees in the US have started calling for the degree to form the basis of their education. Does it help?

Unfortunately there isn’t much high quality evidence from my country to really suggest that degrees have improved patient outcomes – so it’s going to be hard to answer that one definitively, and I don’t know if you can design a study to do so. But here are some general musings on the topic, and why it may not do what you want it to do.

Good Things:

  • There’s more knowledge to work with. The typical degree contains a fairly extensive unit (or more, I did four) of anatomy, physiology, and pathophysiology, along with pharmacology. These tend to be cross-disciplinary subjects so they’re fairly generalist and not EMS-specific; so you get a very good overview of things you might not otherwise consider. While EMS-specific programs focus on only the ‘need to know’ stuff, the degree will give you a general introduction. Understanding anatomy and physiology makes a big difference to understanding basically anything else; with a good background in this, you can pick up most any medical book and get something out of it.
  • It garners a little more respect. A common refrain by the general public is “Oh, you need a degree to do this?” as if it’s some sort of great achievement. It really isn’t, because the degree isn’t hard, but it does at least help build the case that you’re a prehospital professional who did more than sit through a first aid class. And believe it or not, some ignorant members of the public believe that ‘paramedic training’ is just a first aid certificate.
  • It hypothetically enables better decision-making. The more you know, the more you can do – at least so the theory goes. While US paramedics focus heavily on skills and protocols, in Australia we work predominately on guidelines – that is, while we have some hard limits on what we can or can’t do (usually related to drug dosages), a lot of what we do is otherwise at our discretion. That requires that we have a higher degree of knowledge – the more we know, the better we’re able to decide on what to do about something. The difference for me is highlighted in this line that a colleague said to a student: “You don’t need to know patho or any of that shit, just a load of signs and symptoms and how to treat them.” This attitude worked fine back when it was all protocols and limited therapies, but now we provisionally diagnose (to the best of our capability) conditions and treat accordingly (or in some cases, refer accordingly). The difference is in treating “a gastrointestinal problem” and treating “gastroenteritis”. That might support more advanced therapies or referral.
  • It provides a foundation for further knowledge. The basics taught in the degree (mostly in A&P and fundamentals of paramedicine) remain current for long periods. This allows students to go on to higher level qualifications (like a graduate diploma or masters) and pushes the knowledge base even further for critical care paramedics.
  • Hypothetically, it provides better care. More knowledge means being able to better assess patients, which might lead to better outcomes. After all, knowing about Sgarbossa criteria might be the difference between “Oh yeah that’s a weird LBBB and she’s probably had it for ages” and “Shit, we’d better get moving.” But again, I haven’t seen any data to support this in my country.

Bad Things:

  • The theory practice gap is huge. Clinical placements are highly limited – a student might be lucky to do 18 weeks over the course of their 3 year degree. That leaves them with a load of knowledge (much of which they seem to forget) but very little capacity to put it into practice. That’s why, much like nursing, we have graduate paramedic programs that are mandatory before obtaining ‘qualified paramedic’ status. Tossing these students straight into a qualified position resulted in absolute chaos. The US system, for all its flaws, probably creates students that are better able to adapt to the live environment without that lengthy graduate period that our students have. Unfortunately, there’s no way to accommodate so many students for more placements.
  • A lot of people still operate on basic principles due to a lack of diagnostic power and risk assessment. While we have a lot more knowledge, many of us still rely on a few basic principles – and abdominal pain is a great one. Even though we might go “Oh that sounds like cholecystitis” or “Well shit, might be mesenteric ischaemia”, in pretty much all cases we’re going to just load them up with analgesia, correct fluid deficits, and transport. In some cases, we’ll refer people to other services (or leave them at home) – at least until someone gets it wrong and we get spooked. While we can make some pretty big calls (e.g. not treating that chest pain as cardiogenic) we also rely on the crutch of transport to hospital. This is probably down to a lack of diagnostic capacity in the prehospital environment, and conducting a risk assessment of “How sure am I? What happens if I get it wrong?” Unfortunately, people have gotten this wrong and left very unwell patients at home – and they’ve died. So for all the extra education, it might not always be of benefit. Also, the degree program still run scenarios that are basically checklists based on local protocols – so students are effectively railroaded into protocol-based thinking anyway.
  • A lot of students have poor understandings of paramedic care or major concepts. Plenty of students can tell you all about the cath lab. Plenty can tell you all about what’s in the thoracic cavity. Most can explain the basics of shock (repeat after me: pumps, pipes, fluid!). But plenty of them can’t explain what minute volume is. They don’t know when to ventilate a patient outside of obvious apnoea. They don’t understand acid-base imbalances in the prehospital environment. They don’t really understand the response to shock save for some basics like tachycardia and vasoconstriction. While they know a load of advanced concepts, including some generalist concepts, they lack a lot of core prehospital knowledge. But that’s the fault of the universities who push textbooks like Textbook of Adult Emergency Medicine (aimed at interns in an ED) and Emergency and Trauma Care for Nurses and Paramedics (aimed almost entirely at nurses in the ED) – textbooks which don’t deal with the basics (Adult EM) or the advanced clinical decision-making concepts (Emergency and Trauma Care) that paramedics rely on. Gone are the Nancy Carolines and Mosbys – replaced with the aforementioned books that leave students without much of a clue away from the flashing lights of the ED monitors. That said, a textbook like Adult EM is actually a very good thing for the degree; but it isn’t a replacement for a prehospital book that deals with our unique environment. Attempting to teach it as “just the ED except it isn’t in the ED” has largely failed students; the diagnostic approaches rely on bloodwork or imaging that we’re not going to routinely deploy for a long time yet. Textbooks like Nancy Caroline might need to be supplemented with a good A&P book and a good EM book (and maybe a pathophysiology book too) but they do provide those fundamentals of care that are sorely missing from other books.
  • It doesn’t necessarily translate to better pay. In the US it might make the argument for more pay – but it doesn’t automatically lead to higher pay. My scope of practice increased significantly over 2 years, and I got paid a total of $0.90 extra an hour – and that had nothing to do with the degree or the scope of practice change. Paramedics in another state weren’t even reading 12 lead ECGs and they were paid more than me. They did a degree too. The point is that you’re paid what they think you’re worth, and an expensive bit of paper doesn’t automatically open the gates for a pay increase. It might, but it might not.
  • The diploma program was fairly involved, too – save for some topics. Most states offered a diploma instead of a degree as an ‘off the street’ entry; this was a 3 year student program which saw you employed full time, with a gradually increasing scope of practice and educational scope. At the end you were fully qualified and earned a diploma. The diploma was much more focused on the practical side of paramedicine (while the degree is much more about the theoretical side) – thus, a lot of the diploma paramedics lack the strong A&P background of the degree paramedics. But the diploma paramedics generally perform better on jobs because of that experience and focus on the practicalities of the role. Did this mean that non-cardiac chest pain was being treated as potentially cardiac? Yes. Did this mean that the gastroenteritis patient who probably didn’t need to go get transported? Yes. Did this mean that things were driven by protocol and not clinical practice? Debatable. Again, there’s been no decent evidence to support it either way, but by my own observation, a significant portion of jobs ended up being run no differently whether it was a diploma or degree officer running the job. The degree officers offer another perspective, and sometimes build a more complete picture, but it doesn’t necessarily impact the clinical outcome.

To conclude: It’s inconclusive

To be honest, my degree program left a lot to be desired. I know a lot more now as a qualified officer from doing my own readings and research than I did as a student – and that’s because I allowed myself to be spoon-fed lectures, followed the little checklists for scenarios, and read the textbook and journal article sections I was assigned. Plenty of students never purchased or opened a book and relied entirely on the lectures and tutorials. But when I came out on road and started to look at other educational materials, I realised I really didn’t know as much as I thought I did. I initially turned to traditional paramedic textbooks, and my practice actually significantly improved – because I was learning things relevant to prehospital care, things that were practical and applicable to my environment. It was only after gaining that background that I could start to really bring in the more advanced concepts; the concepts that the degree hinted at but never really matched.

The degree gave me loads of foundation knowledge that I still use today to inform and improve my practice; without that fundamental anatomy, physiology, and pharmacology, I’d never get anywhere. But it didn’t teach me a whole lot about how to be a paramedic, or how to make clinical decisions – and the students that I mentor seem to suffer the same problems.

Finally, as a damning criticism of the program – it exists purely to make money. Graduates are pumped out at obscene numbers and rates, and failing students is almost impossible. A student can be totally incompetent on placement, but the university will give them a scenario, and if they ‘pass’ (that’s 50% of things done correctly), they will still pass the unit. I know one student (now graduated) who was absolutely awful on placement and was failed – but the university passed him. He’s now practically unemployable because of how awful he is. But the uni doesn’t care – they got his 3 years’ worth of tuition fees.

So will the degree make a difference? That’s uncertain. Does it usher in a utopia of practice? Not necessarily. But it might help you get there.

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